160 Clayton Dr _ DAVIE COUNTY HEALTH DEPARTMENT
",-• r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
wNOTE:-Issued in-Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and D' posal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 03
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size -J' House Mobile Home _ Business __. Speculation
w No. Bedrooms No. Baths ' l No. in Family r
Garbage Disposal YES Q NO Specifications for System:
Auto Dish Washer YES NO ❑ ,, , ,f
Auto Wash Machine YES NO
Type Water Supply
'This permit Void if sewage system described el w s not installed within 36 months from date of issue.
Improvements permit by �'�'-!%
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
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_ G
E" Certificate of Completion Date
•Thesi Hing of this certificate shall indicate that the system described above has been installed in!compliana with
the standards set fo h jn the above regulation, but shall in NO way be taken as a guarantee that,t11, ''system will fbnction
satisfactorily for anygi en period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS. PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
tie a /`d 7 a yaG/n/ Home Phone
1. Permit Requested By 'e is (>!/SPf.sK i' Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions C",�n--l-d V2Gj 9 sff
Bed Rooms_3 Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes 3 urinals garbage disposal
lavatoryy showers �� washing machine
dishwasher ) sinks 2-
8. a) Type water supply: Public Private—Community
b) Has the water supply system been approved? Yes No..X
9. a) Property Dimensions 6 &C" -e
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?1�es
What type? U it A<, b�c➢� i</ �!/s�<t�•Pyl�
This is to certify that the information is correct to the best of my knowledge.
7 /Z--�() i(� 4�1 1�'7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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